16 March 2011

I've remarked in the past how rarely I ever learn anything useful from physical exam. It's one of those irritating things about medicine -- we spent all that time in school learning arcane details of the exam, esoteric maneuvers like pulsus paradoxus, comparing pulses, Rovsing's sign and the like. But in the modern era, it seems like about half the diagnoses are made by history and the other half are made by ancillary testing. Some people interpreted my comments to mean I don't do an exam, or endorse a half-assed exam, which I do not. I always do an exam, as indicated by the presenting condition. I just don't often learn much from it. But I always do it.

The other day, for example, I saw this little old lady who was sent in for altered mental status. There wasn't much (or indeed, any) history available. She was from some sort of nursing home, and they sent in essentially no information beyond a med list. The patient was non-verbal, but it wasn't clear if she was chronically demented and non-verbal or whether this was a drastic change in baseline. So I went in to see her. I stopped at the doorway. "Uh-oh. She don't look so good," I commented to a nurse. As an aside, this "she don't look so good" is maybe 90% of my job -- the reflexive assessment of sick/not sick, which I suppose is itself a component of physical exam. But I digress. Her vitals were OK, other than some tachycardia*. Her color, flaccidity and apathy, however, really all screamed "sick" to me. Of course, the exam was otherwise nonfocal. Groans to pain, withdraws but does not localize or follow instructions. Seems symmetric on motor exam, from what I can elicit. Belly soft, lungs clear. Looks dry. No rash.

Sigh. Probably another case of urosepsis. Sorry, I mean UTI with sepsis. Boring, and unsatisfying. Let's scan her and cath her and lab her and see what shows up. Let me just take a look at her legs and make sure there's no cellulitis or anything there. Nope, but boy she really groaned when I moved that leg, didn't she? Weird. Seems that left hip hurts her when I push on it. Did she fall out of bed? Maybe she's got a broken hip. Is there a bump on her head? That would explain the altered mental status. Nope. So I flip up her gown to look at the hip better, and I was surprised to see a bright red rash all around her leg and pannus (she was quite large). Huh. Here we go -- she has a rip-roaring cellulitis. That would explain the altered mental status quite nicely. Good. I'd better take a look at her backside, though. She might have a pressure sore there that could be the source, and we have to document that it was present on admission. The nurses glared at me a bit, but we got a team together and rolled her on her side so I could examine her sacrum. No pressure ulcer, and I was about to let them roll her back, when I noticed something -- "Hey, what's that?"

It was a little dark area, like a bruise, just the size of a quarter, on the back of her thigh. But it wasn't quite like a bruise -- it was too sharply demarcated, and too dark, almost black. I poked at it, but she didn't groan, and the skin was intact. Weird. It was involved in the cellulitic area, though.

I didn't like it. So as I put in the orders I decided to add on a CT scan. Shortly afterwards, the labs started to come back, and it was clear this was looking serious. White count of 22,000. Glucose 950. Creatinine 3.5. All bad. Then the call from the radiologist**. I pulled up the images:

There was extensive air all through the soft tissues of the thigh, tracking to the perineum and the abdominal wall. Aha! Now this made perfect sense. She had necrotizing fasciitis, commonly known as the "flesh eating bacteria!" This is a true surgical emergency, and indeed she got a very big surgery. The whole area involved simply had to be excised, and in such a sick patient, that's a huge operation, with a very high mortality. When the famliy eventually showed up, I prepared them with the "she may very well not survive" talk. (And, yes, it turned out this was a dramatic change from her baseline level of function.) To everyone's great surprise, she did pull through the surgery (and the repeat surgeries), and last I saw was getting prepped for discharge to rehab.

The take home point here, really, was that the physical exam, while a rote and generally unrevealing exercise, simply cannot be skipped. This lady had no crepitance -- the crackling underneath the skin that is classically the hallmark of subcutaneous gas. I think she was just too fat, and the thigh too tense, and maybe the air too widely disseminated. If I had not taken the time to look at her backside, I would never have seen the black spot that clued me into the fact that this was more than a routine cellulitis. Had I sent her to the floor on antibiotics, she would have died. This is not at all to be taken as a recantation of my original thesis: in 99% of cases, I learn little to nothing from the exam. She just happened to be in the 1% that actually had a critical finding, which proves the corollary to my thesis, that despite the seeming pointlessness of exam, you still have to do it.

* pro tip for Emergency Medicine interns: respect tachycardia.

* pro tip #2: the radiologist never calls to discuss the fortunes of your local sports team, or a pleasant surprise he experienced in the market. It's always Somethign Bad when the radiologst deigns to speak directly to the emergency physician.

25 comments:

Interesting/Exciting/Sad case. I enjoyed following along with your thought process as you worked through things. Did you ever figure out what exactly this dark spot was on the back of her leg? Was it a bite of some sort?

For me the physical exam begins as you noted when you walked in the room and said, "Uh-oh. She don't look so good." You were already picking up on skin color, alertness, etc. The physical exam is very important as this case shows.

"pannus"Pannus is a medical term for an abnormal layer of fibrovascular tissue or granulation tissue. Common sites for pannus formation include over the cornea, over a joint surface (as seen in rheumatoid arthritis), or on a prosthetic heart valve. Pannus may grow in a tumor-like fashion, as in joints where it may erode articular cartilage and bone. The term pannus is often used incorrectly to refer to a panniculus (a hanging flap of tissue).

I teach the almost lost art of physical diagnosis and see this misuse of the term frequently-especially since the incidence of panniculi is SKYROCKETING!

I have to ask what may be a dumb question here, but let's say that you don't notice the air under the skin (because of the legitimate reasons you listed). Are you liable if something had happened to her? I ask because it seems like in this case that a sharper-than-usual eye actually made the diagnosis, while another doctor, acting completely appropriately, may have missed that.

While I assume you are right in the denotation, I would offer that "pannus" is a more accurate term. Both Latin words mean the same thing -- literally a cloth or a garment -- there's 12 years of catholic education for you!. The difference is the "iculus" format which is a diminutive. "Pannus" means "garment" and "Panniculus" means "little garment." As you can see from the images, there was nothing diminutive about this particular example! Also, language is evolving (blah blah blah) and pannus has become the more or less common term for the big belly roll of fat. I would bow to the inevitable on this, and let the dictionaries catch up in their own time.

Jedi -- I assume the black spot was an area of necrotic/dead tissue immediately underlying the skin.

Not House -- you are ALWAYS liable. Even now, I am sure I could be sued in this case for some real or imagined delay in diagnosis/consultation/treatment, and a credible if bogus argument could be made to a jury that my lack of speed contributed to a poor outcome. The question is whether you could defend yourself and your care, which is entirely dependent on whether you did a good job documenting things, and whether you did the other critical elements of care. Supposing the black spot was not in evidence, which is highly possible, and I put her in the ICU on good antibiotics, vasopressors and got an ICU doc to take care of her, I would probably have been OK, so long as I documented the absence of findings of nec fasc. It would have been better had I documented that I considered nec fasc and maybe gotten a surgical consult.

In either case, now that I think about it, I suspect this diagnosis would have been made on CT, since with a big red leg with no source in a fat septic diabetic person, you really have to consider nec fasc until proven otherwise, and abscess should also have been looked for. Had I sent her up and let the ICU doc get the scan, I might be in trouble.

I would still say it's nearly all in the history and ancillary testing...I can get 80% of my 'useful' PE just by walking in the room or looking over the desk at the patient...the other 20% is split between very gross mental status exam, touching the radial pulse, rocking my hand on the belly, and looking for obvious external infxn (skin), and sticking the ultrasound where I think it should be stuck (this is part of the modern EM PE, NOT part of ancillary testing).

I wish I could could the number of tension pneumothoraces who had bilateral breath sounds on exam (i.e. lots). Physical exam is insensitive for PTX. The old teaching was that you should never see a tension pneumo on x-ray because the diagnosis should be made clinically. That's a lovely myth, but the reality is that if you wait for the clinical signs to emerge, you've got a very sick patient and you waited too long to get the x-ray.

Having said that, it's certainly true that there are TONS of presentations which really are about the exam (bronchiolitis, stroke, etc).

As a medic and now a nurse working in a TB ward in Haiti,often the clinical exam skills we have are all there is. The learning curve down here (Haiti) has been steep but I am gaining skills that will serve me throughout my career. Never underestimate the value of a good exam.

A large advantage of having this process performed is the prevention of larger health concerns. This prevention tool is usually aimed at being able to spot larger issues from occurring using blood work and a basic review of the body. This is often all that is require for preventing future issues.

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Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

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